Working Papers

Physician Behavior in the Presence of a Secondary Market: The Case of Prescription Opioids
(Draft available upon request)

Abstract: While reports of pain have remained stable over the last 15 years, the use of prescription opioids in the United States has more than quadrupled since 1999. This dramatic expansion in the clinical use of opioids has led to a new wave of drug addiction, with prescription drug overdoses surpassing auto fatalities as the leading cause of accidental deaths in 2008. In this paper, I consider how the presence of an illegal market in which patients can reallocate opioid prescriptions influences the prescribing practices of physicians. Introducing a framework that incorporates supply and demand for opioids in both the legal, primary market and the illegal, secondary market, I demonstrate that the secondary market polarizes physician behavior on the primary market: that is, lenient prescribers become even more lenient in the presence of a secondary market whereas strict prescribers become even more strict. Applying this framework, I will measure how the effectiveness of enforcement policies targeting a single market is eroded by feedback across these markets. Taking into account this feedback, I will further identify policies that will be successful in curbing opioid abuse across the diverse environments found in the US.

Is the Focus on Food Deserts Fruitless? Retail Access and Food Purchases across the Socioeconomic Spectrum 
(NBER Working Paper No. 21126) with Jessie Handbury and Ilya Rahkovsky

Abstract: Using novel data describing the healthfulness of household food purchases and the retail landscapes consumers face, we measure the role of access in explaining why wealthier and more educated households purchase healthier foods. We find that spatial differences in access, though significant, are small relative to spatial differences in the nutritional content of sales. Socioeconomic disparities in nutritional consumption exist even among households with equivalent access, and the healthfulness of household consumption responds minimally to improvements in local retail environments. Our results indicate that access-improving policies alone will eliminate less than one third of existing socioeconomic disparities in nutritional consumption. 

Check Up Before You Check Out: Retail Clinics and Emergency Room Use 
(NBER Working Paper No. 23585) with Diane Alexander and Janet Currie

Abstract: We use the universe of emergency room (ER) visits in New Jersey from 2006-2014 to examine the impact of retail clinics on ER usage in a difference-in-difference framework. We find significant effects of retail clinics on ER visits for both minor and preventable conditions, with residents who live close to an open clinic being 4.1-12.3 percent less likely to use an ER for these conditions. Our estimates suggest annual cost savings from reduced ER usage of over 70 million if retail clinics were to be readily available across all of New Jersey.

Addressing the Opioid Epidemic: Is There a Role for Physician Education? 
(NBER Working Paper No. 23645) with Janet Currie

Abstract: Using data on all opioid prescriptions written by physicians from 2006-2014, we uncover a striking relationship between opioid prescribing and medical school rank. Even within the same specialty and county of practice, physicians who completed their initial training at top medical schools write significantly fewer opioid prescriptions than physicians from lower ranked schools. Additional evidence suggests that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools. Altering physician education may therefore be a useful policy tool in fighting the current epidemic.

Closing the Gap: The Impact of the Medicaid Primary Care Rate Increase on Access and Health 
(FRB of Chicago Working Paper No. WP-2017-10) with Diane Alexander

Abstract: The difficulties that Medicaid beneficiaries face accessing medical care are often attributed to the program's low reimbursement rates relative to other payers. There is little evidence, however, as to the actual effects of doctor payment rates from Medicaid on access and health outcomes for beneficiaries. In this paper, we exploit within-state variation in Medicaid reimbursement rates driven by the Medicaid fee bump—a provision of the Affordable Care Act mandating that states raise Medicaid payments to match Medicare rates for primary care visits for 2013 and 2014—to quantify the impact of changes in physician payment on access to treatment. As Medicaid rates are set at the state level and vary considerably in generosity, the policy had a large and heterogeneous impact across states. We find that increasing Medicaid payments to primary care doctors is associated with significant increases in office visits, improvements in access measures, and better self-reported health among Medicaid beneficiaries. Among children on Medicaid, fee increases are also associated with fewer days of missed school.

Just What the Nurse Practitioner Ordered: Independent Prescriptive Authority and Population Mental Health 
(FRB of Chicago Working Paper No. WP-2017-8) with Diane Alexander

Abstract: We examine whether relaxing occupational licensing to allow nurse practitioners (NPs)—registered nurses with advanced degrees—to prescribe medication without physician oversight is associated with improved population mental health. Exploiting time-series variation in independent prescriptive authority for NPs from 1990–2014, we find that broadening prescriptive authority is associated with improvements in self-reported mental health and decreases in mental-health-related mortality, including suicides. These improvements are concentrated in areas underserved by psychiatrists and among populations traditionally underserved by mental health providers. Our results demonstrate that extending prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations.

Non-refereed Publications

Evaluating the Economic Response to Japan's Earthquake
with David Weinstein
RIETI Policy Discussion Paper Series 12-P-003, February 2012